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"�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ow Year
,_ _; FOR DEDUCTION FROM ASSESSED VALUATION
: . . State Fortn 93709 (R77 /6-09)
S�.,� � Hesa�bed by DepartrreN of Lo�l Govemmerit Firence
File M� rk 11
wsrRUCnorus:
b 6e filed in person oi by mail with the CountyAuditw or Counry Recorder of the county where the property is located. ����
Filirg Dates: 1) Real Property: Must file dunng fhe yrear /or which the deduction is soaght. C. , ditor
2) Mo6Be / Manufactured Homes nof assessed as Real PrUperty: Musf file dunrg fhe fweNe (12) months ❑ �
before March 37 o/eacA year the deduction is sought.
See reverse side /or addi�onel instiuctions arM qualifications.
npacam (oirner ormrr'�eq bu�r - see mstrir�br��n re�r¢e sEeZ
� N \ � I lw � 1 I 1/ 1 i
]f R21 WOP�Y 2S Of
7�
M 110. W�18� 6 �I15 / i12f EZLf2 5�12IB Oi YIiClP3l�
If name on rt,md'S difie2nt Nan Nat W appGrar�t, uMinte Celmr.
ALdress d rtart9a9� w contract seder (num6rsand sneel mY. �.
Nama a1 azsipiee or a'her owner or holder of m
Atltlress af azsgnee (number aiM stree4 �; st
any
Detluction approved m tl�e amount M:
20
signature W CamN nwitw
C
: � .
.�
as of Is Ne eppfxant Ne 5Ne
k9a1 a eQUltatle awnel?
❑ Yes ❑ No
H owned wiN sorreone oUrer than spouse. IMicate with whom
Dra��•er \O.. .�rl.� I.�........
Card NO. ...:��D�J�........
,� 183, I$0.°�
20 � 20 _ � 20 � 20
Counry
J
Is tlre P�PQrtY in 7uestion: MnuaM Assesse0
❑ Real Roperty Q Atmually Assessed
Has �his Cetludim Eeen reGuesfeA m G��Y
for wrrent Ye� ❑ Yes ❑ No
� � �
I I We certify under Ne penalry of perjury that the above and foregoing infortnalion is true and cortect arW Nat the applican[ is a resident of Indiana and
owner I contracl yer of e aforementi ed prope on date applicatlon is filed.
� (o me) ! Dale (morvh. eay, yee
�"�� `��� n� I �. 4 �_ �O_ ii
Person
�
auCmrzed persm (numberaM sveet, ciry, sb(e, and LP code)
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